Vaginal cancer is a primary or metastatic malignant lesion of the mucous membrane and walls of the vaginal tube. There is no early clinic for vaginal cancer; the appearance of abnormal spotting and pain occurs in the late stages of tumor growth. Gynecological examination, colposcopy, cyto-morphological examination of smears and biopsy material are used in the diagnosis of vaginal cancer. In the treatment of vaginal cancer, surgical intervention (removal of the vagina and uterus), radiation and chemotherapy are used.
Vaginal cancer is usually localized on the back wall of the upper part of the vaginal tube, can spread to surrounding tissues and organs (paravaginal tissue, rectum, vaginal-rectal septum, bladder), and also give distant metastases. Metastasis occurs mainly by the lymphogenic route; metastases are more often found in the iliac-obturator, anorectal, sacral, inguinal-femoral lymph nodes.
Primary vaginal cancer in gynecology accounts for 1-2% of all malignant tumors of the female genital area; secondary (metastatic) is detected much more often, the primary focus in these cases is usually cancer of the cervix, endometrium, sarcoma and chorioncarcinoma of the uterus, ovarian and kidney cancer.
To date, the causes of this pathology have not been clarified, but there are endogenous and exogenous factors that provoke the development of the tumor process. The background for the development can be chronic infections (primarily HPV types 16 and 18), vaginitis, genetic predisposition, vaginal adenosis, endocrine disorders (including postmenopausal hypoestrogenia), decreased immune status, stress, chronic irritation of the vaginal walls (wearing pessaries during uterine prolapse), smoking, radiation exposure impact and reconstructive plastic surgery.
Disease is detected mainly at the age of 45-65 years, and light-cell adenocarcinoma usually occurs at a young age (19-20 years), and squamous cell carcinoma – in the older age group. Precancerous changes, as well as cervical cancer and vulvar cancer, increase the risk of developing squamous cell carcinoma of the vagina. Squamous cell carcinoma of the vagina can develop against the background of a precancerous condition – intraepithelial neoplasia (dysplasia) of the vagina. It has been proven that the occurrence of clear-cell adenocarcinoma of the vagina and cervix in women is associated with the intake of diethylstilbestrol by their mothers during pregnancy, especially in the first 16-18 weeks.
Vaginal cancer can occur from epithelial cells (including ectopic), vaginal glands, smooth or striated muscles of its wall. According to histological signs, squamous cell carcinoma of the vagina is isolated (in 95% of cases), adenocarcinoma (endometrioid, light cell); melanoma, sarcoma (leiomyosarcoma, rhabdomyosarcoma).
Disease is classified according to TNM criteria (size, lymph node lesion, presence of distant metastases) and stages (FIGO). Tumors involving the external genitals are referred to as vulvar cancer; with the spread to the vaginal part of the cervix – to cervical cancer.
- Stage 0 (Tis) – preinvasive vaginal cancer (in situ)
- Stage I (Tl) – the tumor process is limited to the vagina, the diameter of the primary tumor is up to 2 cm
- Stage II (T2) – tumor growth spreads to the paravaginal tissues, does not reach the pelvic walls; the diameter of the primary tumor is over 2 cm
- Stage III (TK or N1) – tumor growth spreads to the pelvic walls, the presence of regional metastases
- Stage IVA (T4) – vaginal cancer grows into the urethra, bladder, rectum, pelvic bones, perineum; regional metastases are determined
- Stage IVB (Ml) — the presence of distant metastases of vaginal cancer.
Symptoms of vaginal cancer
In the early stages, disease occurs with absent or poorly expressed symptoms. Pathology patients may be disturbed by discomfort, itching in the genital area. Clinical manifestations occur as the tumor grows in the late stages of vaginal cancer. At the same time, watery or pus-like white spots, sucrovich and bloody discharge, abnormal bleeding from the vagina appear: spontaneous (in the middle of the menstrual cycle, during menopause) or contact (after sexual intercourse). There are pains in the pubic area, perineum, giving to the lower back, painful sexual intercourse.
The progression of vaginal cancer due to metastasis to regional lymph nodes and invasion of surrounding tissues can cause a violation of the function of the intestine and urinary system (frequent and painful urination, constipation, chronic pelvic pain). The general state of health is disturbed: weakness, fatigue, anemia appear, the temperature rises, swelling of the lower extremities develops.
The diagnosis of vaginal cancer is established by a gynecologist on the basis of complaints, the results of gynecological examination, instrumental laboratory studies (colposcopy, cytological examination of smears from the affected areas, tumor biopsy with histological examination of the material).
Vaginal cancer in the early stages may have the character of submucosal infiltration, small ulceration, papillary growths. The exophytic tumor has a bumpy surface, can easily be injured and bleed; the ulcerative tumor is surrounded by a dense roller; endophytic vaginal cancer with invasion into the surrounding tissues is characterized by immobility and increased density.
To exclude metastases of primary vaginal cancer, separate diagnostic curettage of the cervical mucosa and uterine walls, ultrasound of the pelvic organs, rectoromanoscopy, excretory urography, cystoscopy, abdominal ultrasound, chest X-ray, mammography, MRI and CT are performed.
Vaginal cancer should be differentiated from chorionepithelioma and cervical cancer metastases; benign vaginal neoplasms (papillomas, genital warts, hemangiomas); hyperplastic processes and endometriosis; lymphoma; pressure sores; colpitis; syphilitic and tuberculous ulcers.
When choosing a method and treatment plan for vaginal cancer, the following factors should be taken into account: the localization and degree of invasion of the tumor into surrounding tissues and organs, the stage and duration of the disease, the general condition of the patient, her age, the desire to have children, the side effect of various types of therapy. The main schemes of treatment of vaginal cancer, which are used by modern gynecology, are surgery, radiation and chemotherapy.
In non-invasive vaginal cancer (localized form with monocentric growth), surgical treatment includes electroexcision; in the case of multicentric tumor growth, vaginectomy and hysterectomy. Acid laser therapy and cryodestruction of a tumor focus are considered to be quite effective. Chemotherapy in the treatment is used less often, in the form of local applications with fluorouracil. In the modern treatment of preinvasive vaginal cancer, photodynamic therapy is used, in case of ineffectiveness of local exposure, radiation therapy is indicated.
The main method of treatment of invasive vaginal cancer is radiotherapy (radiation therapy), including remote, intracavitary (endovaginal) and interstitial irradiation. Depending on the stage of vaginal cancer, X-ray therapy, gamma therapy and intra-cavity administration of radioactive drugs are used separately or in combination with each other. With advanced tumor processes, irradiation of the affected area, parametric tissues and pelvic lymph nodes is carried out. It is possible to combine radiation therapy with chemotherapeutic and surgical treatment.
Indications for surgical treatment for invasive form are limited. With a tumor of the upper third of the vagina, young and middle–aged patients are removed from the upper part of the vagina with the removal of the uterus and appendages; in combination with cervical cancer, a pangisterectomy with excision of the pelvic lymph nodes is mandatory. In patients with stage IV vaginal cancer complicated by rectovaginal or vesicovaginal fistulas, pelvic exenteration and pelvic lymphadenectomy are performed.
Patients should be monitored by an oncogynecologist at a dispensary with regular examination (examination, ultrasound, cytological examination).
With early diagnosis and treatment of this disease, the prognosis is favorable; with late detection of the disease, it depends on the stage of tumor development and its morphological structure. The five-year survival rate of patients after treatment of vaginal cancer is: at the I st. – 65-70%; II st. – 45-60%; III st. – 30-35%; IV st. – 15-20%.